Purpose: To study and understand the contribution made by Adam Politzer (1835-1920) to 20th century otology and analyze his place in the history of otology.

Method: A study of his four reference works, some of his hundreds of publications in medical journals, and diverse publications written about him.

Results: All areas of otology have been studied, compiled, and improved through his assorted publications, notably his atlas of otoscopy published in 1865, the first work of its kind, expanded and reedited in 1896; his l O tables of the anatomy of the ear amended in 1873; his textbook of the diseases of the ear, which was first published in two volumes in 1878 and 1882 and subsequently reedited four times as one volume, the last time being in 1908; his anatomy and histology book published in 1889; and his book on the history of otology, which up to now is the most complete tome existing on the subject, edited in two volumes in 1907 and 1913. No other has been as prolific as he. He invented, in particular, a revolutionary method of making the eustachian tube permeable—a method that made him famous and carries his name. He also developed an acoumeter to measure hearing and was the first to describe certain pathologic conditions histologically, of which otosclerosis is one.

Conclusion: Politzer is certainly the greatest otologist of the 19th century and probably one of the greatest of all time. His influence on the 50 years of otology has never been equaled. He deserves a double mention in the history of otology: as an otologist and as a historian. It is in his honor that the Interna­tional Society of Otology bears his name.

(*)Published in Am J Otol 21:753-763, 2000 and inserted here with the permission of the Publisher Lippincott Williams and Wilkins.

"Everything is connected with everything." Adam Politzer

All non-exhaustive historical reviews are open to criticism because of the author's choice of essential events and those of fellow contributors. It is rare that improvements are made by one single researcher. Otology, like all the other branches of medicine, has been marked by some great names, such as Guichard Duverney, Domenico Cotugno, Herman von Helmholtz, Anton von Troeltsch, Joseph Toynbee, William Wilde, Prospere Meniere, Jean-Marie Itard, Adam Politzer, Julius Lempert, Horst Wullstein, and Harald Schuknecht, to name but a few of the most renowned. The most eminent of them all is probably Adam Politzer. He left his name to posterity not only as an otologist but also as a historian.

Adam Politzer has already been the subject of many publications paying him homage, often putting the emphasis either on certain aspects of his life or on his scientific works. His original works will be used as a ref­erence for this study, which is primarily concerned with the analyses released at the time they were published. A brief biography will be followed by an analysis of his books and a few of his publications. These provide the background for an understanding of his contribution to otology and his place in its history.

BIOGRAPHY

Adam Politzer was born on October l, 1835, in Alberti, now known as Albertirsa (1), Hungary (Fig. 1). He was the son of a merchant. He went to school in Kecskenet and obtained his high school certificate in Pest. He studied medicine in Vienna and became a doctor in 1859. He was instructed by Kari von Rokitansky, Joseph Hyrtl, Johann von Oppoltzer, and Joseph Skoda, among others (2). It was during this time that laboratories be­came indispensable for clinical and histologic analysis. They were also the place of research into the causes of pathologic processes. The realization of this medical re­form linked diagnostic procedures to causal theories based on physiology and pathology. Adam Politzer was greatly influenced by this laboratory medicine and had the opportunity of working with the greatest European minds. He learned physiology under the guidance of Kari Ludwig in Vienna and Heinrich Müller in Würzburg. His first work on the nerve supply of the internal muscles of the ear and the influence of pressure modification in the tympanic cavity on the pressure in the interior of the labyrinth was published in 1861 (3). That same year, he began microscopic study of the labyrinth with Albert Kölliker in Würzburg and became friends with Anton von Troeltsch. He went on to work with Hermann von Helmholtz in Heidelberg and then his student Rudolf Körni in Paris to improve his knowledge of auditory physiology. His studies in Paris were completed by his contacts with Claude Bernard of The College of France and Prospere Meniere of the Deaf and Dumb Institute of Paris. Finally, he went to London to be taught the mod­ern techniques of ear surgery by Josef Toynbee.

On his return to Vienna in 1861, he became the first teacher of otology (Dozent) with the backing of Oppoltzer. In 1864, with Anton von Troeltsch and Hermann Schwartze, he created the Archiv für Ohrenheilkunde. This was the first journal to cover only pathologic conditions of the ear. The first edition was printed in Würzburg by Stahel. The fourth and subsequent editions were printed in Leipzig by Vogel. In 1871, Politzer be­came extraordinary professor at the Clinic of Otology in Vienna, and then in 1873 he went on to become the director with Josef Gruber. This was the first establishment in the world to deal solely with otology (4). The clinic comprised about 20 beds, divided between men and women. Despite the number of consultations, 12,000 to 15,000 per year, the clinic was not expanded until 1898. In 1876, Politzer participated in the Centennial Exposition that took place in Philadelphia. Here he presented a collection of dissected temporal bones and molds of ears showing both normal and pathologic states (5,6). These specimens found their way to the Mutter Museum of Philadelphia and are one of the museum's most prized exhibitions. In 1894, Politzer became pro­fessor of otology. In 1895, in the company of Josef Gru­ber and Viktor Urbantschitsch, he founded the Austrian Society of Otology. In 1902, he was adviser to the court of Emperor Franz Josef (Hofrat). He retired in 1907, saying, "As of his day, the historical role of otology has been established in our university." He occupied his spare time by writing the history of otology. He died suddenly on August 10, 1920; he was 85 years old.

Politzer was a man who managed to combine his qualities as a physician, researcher, teacher, and writer (7). He was an artist of talent. He excelled at drawing and in the making of models and molds of the ear. He had great artistic knowledge and over the years collected numerous works of art (8). In his last will and testament, he left a large part of his library to the University of Vienna and most of his preparations and anatomic models to the Anatomy and Pathology Museum of Vienna. The remainder was left to the University of Budapest, the capital of his country of origin.

BOOKS PUBLISHED BY ADAM POLITZER

There is not one single discipline of otology that was not covered by Politzer. However, his preferred subject was always the anatomic pathology of the ear. His works are spread over almost half a century and include more than 100 publications in medical journals and five reference books, of which f our were written by Politzer (9,10). Most of his publications, which appeared in the Wiener Medizinische Wochenschrift, the Wiener Medizinische Presse, and the Archiv für Ohrenheilkunde, were reprinted in his books. From 1896, the minutes from the meetings of the new Austrian Society of Otology were also published in the Monatsschrift für Ohrenheilkunde, in the Annales des Maladies de l'Oreille du Larynx, and in the Journal of Laryngology, Rhinology and Otology. Politzer actively participated during these meetings by presenting or discussing his patients' cases or his ana­tomic preparations. The four books written by Politzer were translated into English. Certain of them were also published in other languages such as French or Spanish.

FIG. 2. Atlas of the
membrana tympani.

His first work to be published was an atlas of otoscopy: Die Beleuchtungsbilder des Trommelfells im gesunden und kranken Zustande (11) (The membrana tympani in health and disease) (Fig. 2). This atlas included 48 drawings made by Politzer himself. It was completed and reedited in 1896 with a slightly modified title: Atlas der Beleuchtungsbilder des Trommelfells im gesunden und kronken Zustande (12) (Atlas of the membrana tym­pani in health and disease). This work was based on a diagnostic approach and the examination of the tympanic membrane with its different normal and pathologic images described by means of its color, transparency, position, integrity, cicatrization, and mobility. Because it was the first real atlas on otoscopy, and with its new approach, it very quickly became indispensable to the study of otology (13). The first edition saw 48 chromolithographies of the tympanic membrane spread over two plates. Otoscopy constitutes the first step in the examination of an ear. For the first time, it was possible to learn in an colored atlas the different pathologic conditions of the tympanic membrane, which is the window of the middle ear. Never before had the diagnosis of oto­logic diseases been presented in such a way, which revolutionized the study of pathologic conditions of the tym­panic membrane. The second edition, however, was completely revised, restructured, and expanded with the addition of many clinical observations and included 392 drawings of the tympanic membrane. The evolution of examination techniques and especially the quality of light used in otoscopy allowed for the realization of this atlas, the most complete and the best at the end of the 19th century (14-19).

In 1873, Politzer designed and published 10 anatomic illustrations under the title of Zehn Wandtafeln zur Anatomie des Gehörorgans (20) (Ten tables of the anatomy of the ear). These anatomic drawings of the ear very quickly found their way onto the walls of most of the centers specializing in otology. They were also used as a teaching foundation by many otologists (21). Again, this was a completely new approach to studying the anatomy of the ear. The students were used to dealing with molds and the small drawings found in the otologic books of this era. For the first time, the drawings were big enough to be studied and explained by a teacher for all students. In this way, the quality of teaching could be perfected.

FIG. 3. Textbook of the diseases
of the ear, first edition

Between the years 1878 and 1882, Politzer published a compilation of all knowledge on otology of the era in two volumes titled Lehrbuch der Ohrenheilkunde für praktische Ârzte und Studierende (22) (A textbook of the diseases of the ear for students and practitioners) (Fig. 3). This work was subsequently reedited into one volume in 1887. It was to be reedited a further three times, the last edition appearing in 1908 (23). Having been translated into many languages, this reference book was used by most of the otologists at the end of the 19th century and took its place in all the otologic libraries. Subsequent editions allowed Politzer to give character to his work and to correct the lack of unity of the first edition (24-28). The second edition, published in 1887 (29-31), the third edition in 1893 (32-35), the fourth edition in 1901 (36-41), and the fifth edition in 1908 reflected the evolution of knowledge and the progress achieved in otology during those 30 years (42). Politzer's Lehrbuch was praised for its uniformity, conciseness, and harmonious treatment of the subject. It was considered a standard volume on the practice and science of aural surgery for over a quarter of a century. The book contained numerous illustrations along with an excellent bibliography. It dealt with such topics as the anatomy and physiology of the sound-conducting and sound-perceiving apparatus, diseases of the sound-conducting apparatus, topography and physiology of the sound-perceiving apparatus, anatomic divisions of the ear, and aural malformations. Politzer's textbook was so complete and so conscientiously kept up that the fourth edition showed how the specialty had advanced in just a few years. The fifth edition showed the advances made in neurotology by the inclusion of radiographs of the ear, surgical techniques by labyrinthine separations, intracranial complications, and infections of the jugular bulb. This last edition was the culmination of Politzer's career and is considered a monumentum aere perennim. It should be present in every library of medicine (42-47).

FIG. 4. The anatomic and
histologic
dissection of the ear.

In 1889, Politzer published a book on anatomy and histology: Die anatomische und histologische Zergliederung des menschlichen Gehörorgans im normalen und kronken Zustande für Anatomen, Ohrenarzte und Studirende (48) (The anatomic and histologic dissection of the human ear in the normal and diseased condition for anatomists; ear, nose, and throat physicians; and students) (Fig. 4). Because anatomic pathology was Politzer's domain of excellence, he could not avoid producing a volume dedicated to this subject, and it was extraordinary. Never to this day has there been as comprehensive a book published on this subject. Used as much by otologists as pathologists, it rapidly became the book of reference for the anatomic pathology of the ear (49-54). Once again, the concept of presenting a com­plete book dealing only with anatomic pathology of the ear was absolutely new. For the first time, the micros-copy of the ear, in normal and pathologic conditions, was accessible to every otologist.

FIG. 5. History of otology, volume 1.

FIG. 6. History of otology, title page of the second volume
by Politzer's hand. (Courtesy of the Institut für
Geschichte der Medizin, Vienna.)

After retiring, he also published, between the years 1907 and 1913, a history of otology in two volumes: Geschichte der Ohrenheilkunde (55). It was reprinted in 1967 in Hildesheim. The first volume was translated into English by Millstein et al. as History of otology (56). After the first volume was published (Fig. 5), this history of otology surprised many otologists by retracing the development of otology from its beginnings up to the middle of the 19th century (57-62). A remarkable work of precision, this book has not been equaled to date. This outstanding work is certainly the golden summit of the career of Politzer. It represents nearly a full life of re-search, compilation, and organization of the otologic knowledge available through the ages. The quality of this book surpassed all existing histories of otology and thus will last forever. Today, it is impossible to learn the history of otology without reading Politzer's book. The second volume (Fig. 6), covering otology during the sec­ond half of the 19th century and the beginning of the 20th, was written by otologists from many countries and is a very good complement to the first volume (63-67). In 1901, Politzer collaborated with Gustav Brühl to publish an atlas of otology: Atlas und Grundriss der Ohrenheilkunde (68-73). It was reedited in 1905 with the modified title of Grundriss und Atlas der Ohren­heilkunde (74-77). The third edition of 1913 had yet another title: Lehrbuch und Atlas der Ohrenheilkunde (78,79). This work was published as Number 24 in the series of pocket atlases of medicine by Lehmann. For the first time, otology was presented by showing the association of normal and pathologic conditions of the ear in a colored atlas form. This presentation of macroscopy with microscopy to explain the different anatomic and pathologic details of the normal and diseased ear was a new concept in studying otology. It very soon found a place in the pockets of many assistants who were learning otology, largely because of its conciseness and the quality of its illustrations.

POLITZER'S CONTRIBUTION TO OTOLOGY

FIG. 7. Politzer's acoumeter.

FIG. 8. Politzer's speculum.

Politzer studied and developed all fields relating to the ear. His scientific works were based on research along anatomic and physiologic lines. He believed that audi­tory testing was very important for the diagnosis of diseases related to hearing loss, because it allowed the degree of hearing alteration to be determined as well as the localization of the lesion within the ear. He distinguished between tests of bone conduction and air conduction. In 1877, he perfected an acoumeter designed to replace the watch in the measurement of hearing (80). This small portable instrument, which he held between finger and thumb, consisted of a small hammer that hit a hollow rod, producing a click of the same caliber as the ticking of a watch but more intense (Fig. 7). It allowed for the perception of sound intensity by both air conduction and bone conduction routes by placement either on the mastoid bone or at the entrance of the external auditory canal. The evaluation of the level of hearing by air con­duction was achieved by measuring the distance at which the subject could hear the sound emitted. This was done independently for each ear. Politzer also tested the per­ception of whispered speech in each ear by repeating different words into the subject's ear without the aid of lip reading.

On a clinical level, he also developed a conical speculum for the external inspection of the ear, which he presented in 1862 (81). This model was slightly improved in 1878, essentially by the use of rubber in its composition (22,82) (Fig 8).

FIG. 9. Hand-held air baÄ for "politzerization."

FIG. 10. "Politzerization" method.

On a therapeutic level, Politzer invented a new procedure for actively inflating the air in the middle ear with the help of a hand-held air bag, which made the eustachian tube permeable (83). This instrument was first pre­sented in 1863 (Figs. 9 and 10). It was based on the fact that during swallowing, compressed air within the nasopharyngeal space, which is closed on all sides, travels through the tube into the middle ear (84,85). The advantage of this instrument was that the accessory was introduced into the anterior part of the nasal fossa. Therefore, there was no need to introduce a catheter into the eustachian tube, a practice that was very impractical and often very difficult for the patient. Thanks to this system, Politzer became famous throughout the world (86,87). The system was modified by Gruber and Lucae (22), who then presented it as a new method of insufflation, and Politzer was forced to react and set the record straight (88,89). In 1873, he also developed ventilation buttons (grommets) for the middle ear, which were put in place after a paracentesis (Fig. 11). These transtympanic aerators were the subject of discussion in the Archiv für Ohrenheilkunde (90,91). In 1881, he perfected a small auditory instrument for people with hearing loss, in the shape of a hunting horn (Fig. 12). The apparatus was placed in the outer ear and slightly amplified the sound heard (92,93). In 1884, he described another small audi­tory instrument conceived on a different system. It consisted of a small tube fixed in the outer ear by means of a piece of rubber; the other end of the tube was placed at the end of the external auditory meatus (Fig. 13). This aid guided the sound directly to the tympanic membrane and provided a slight improvement in sound intensity (94,95).

Politzer was also a great anatomic pathologist of the ear and thus was often the first to describe numerous pathologic conditions, for example, otosclerosis, secretory otitis media, labyrinthitis, congenital deafness, intracranial complications of otitis, and atelectasis of the ear (96). In 1893, he demonstrated that dry sclerotic middle ear catarrh was caused not by an illness of the mucous membrane of the middle ear but by a primary illness of the otic capsule (Fig. 14). This was the first description of otosclerosis (97-102). After having been discussed at length by certain of his colleagues, this theory progressively replaced the others. Politzer also participated in many diverse discussions on the origins of cholesteatoma.

FIG. 11. Politzer's ventilation button.

FIG. 12. Politzer's "hunting horn."

FIG. 13. Politzer's hearing device.

FIG. 14. Otosclerosis.

POLITZER'S PLACE IN THE HISTORY OF OTOLOGY AS AN OTOLOGIST

AND HISTORIAN

Otology as a medical specialty began progressively (103). The first truly modern developments are without doubt due to Adam Politzer (104), who elevated otology to the rank of a medical specialty. In 46 years, he transformed otology from a sterile discipline without hope into an academic discipline recognized as a specialty (105,106). Politzer was an obstinate and untiring worker, putting his teaching and his clinic first and regularly proposing his ideas to his associates, encouraging their use without being directive and using the results to develop an original and often brilliant synthesis. Despite opposition from and inertia of the colleagues who contested his ideas, he gave his nobility to otology.

Otologists worldwide owe a great debt to Politzer. He received over 7,000 foreign doctors in his clinic, always with perfect hospitality; many of these doctors were the great otologists of the era. He was able to teach with the same panache in German, English, French, Italian, Spanish, and Hungarian, all of which he spoke fluently. Well loved by his colleagues and his assistants, he often received tokens of friendship and respect (107-109). His most famous students and successors were Robert Barany, who received the Nobel Prize for medicine in 1914 for his research into vestibular physiology; Hein-rich Neumann; Gustav Alexander; and Eric Ruttin (110).

FIG. 15 Commemorative stamp ofAdam Politzer on the 150th year of his birth.

In his honor, his name is associated with the Interna­tional Society of Otology, founded in 1978. Most of the founding members had participated at the first Interna­tional symposium on middle ear surgery at the Gummersbach City Hospital in Holland in 1971. The success of this first congress motivated the organizers to put in place a structure to improve the scientific program of subsequent congresses. The Politzer Society was born (111). Politzer has the right to a place in the history of otology not only as a practitioner but also as a historian. His History of otology is the most complete work that exists on this subject to date, and it is used as a source of reference by all doctors and historians who are interested in the history of otology. Politzer offered one of the greatest gifts to otology when he left to posterity all of his writings (64). His two places as otologist and histo­rian are in perfect harmony, as Goethe put it so well, "The history of a science is the science itself." in 1985, Austria released a commemorative stamp (Fig. 15) bearing his likeness for the anniversary of his 150th birthday, seen as a supreme recognition of his work as a doctor and otologist (112). Few other otologists had the right to this honor except for two winners of the Nobel Prize for medicine, which was given to two researchers of the inner ear, Robert Barany in 1914 and Georg von Bekesy in 1961.

Much still remains to be written about Adam Politzer. However, it can be said without contest that he was probably the greatest otologist of the 19th century (8,96,113-120). He covered all spheres of otology from clinical otoscopy and hearing examinations to the development of new therapeutic procedures, including histologic examination of the ear and the description of numerous pathologic conditions. He was also a great compiler and collector of otologic knowledge of the era, often at the crossroads of different schools, mainly German, English, and French. It is still very interesting to read his works, because he presents numerous ideas that have still not been developed by modern medicine.

In 1920, a few months before his death, during the 25th anniversary of the Austrian Society of Otology, Politzer declared, "it is the duty of all who have at heart the advance of science, to look undismayed into the future and with all the forces to assume the uninterrupted work. Upon you, my younger colleagues, does this duty rest. It requires now, more than ever, devotion, industry, and perseverance. You are confronted with more difficult tasks than we, your elders, had in former days (though not wholly without struggles), when it was granted us in quiet times to consecrate ourselves to scientific pursuits."(121) the name Politzer is and will remain immortal in the history of otology.